I Treat Patients with Elevated Blood Pressure
Elevated blood pressure, or hypertension, is associated with serious
health problems, such as strokes, heart attacks, and kidney failure.
Most people believe the problem with hypertension is that the elevated
pressure damages the arteries and the body’s organs. Actually, it is
more often the other way around. The rise in blood pressure is a
response to a sick body—the blood pressure goes up as a natural and
proper adaptation—as an attempt to compensate for a plugged up
cardiovascular system. After years of consuming the rich Western diet,
the blood vessels develop blockages referred to as atherosclerosis, the
artery walls stiffen, and the blood itself becomes viscous. All this
change creates a resistance to flow, resulting in a decrease in the
ability to deliver nutrients to the tissues. The body responds, as it
should, with a rise in blood pressure.
The correct action for the patient to take is to decrease the resistance
to flow by eating a healthy diet and exercising. Most people who follow
the McDougall diet find their blood pressure decreases within a few
days. Based on several collections of results from my clinic, the
average reduction of blood pressure is about 14/11 mmHg in seven days,
and at the same time medications used for treating hypertension are
usually stopped. My customary protocol is to stop all blood
pressure-lowering medications the first day of the Program, except for
beta-blockers, which I slowly discontinue by cutting the dosage in half
every two to three days. Unfortunately, not every patient experiences
the reduction in numbers they desire. Despite their best efforts some
people may need medications.
These blood-pressure-lowering drugs function by poisoning the body in
various ways. “Poison” is the correct word. In chemistry poison means to
inhibit a substance or a reaction. Beta-blockers inhibit the action of
adrenalin on the heart muscle, calcium channel blockers inhibit the
contraction of the blood vessels, ACE inhibitors and angiotensin
receptor blockers do just that (inhibit and block) the blood pressure
regulating hormones produced by the adrenal glands, and diuretics poison
the water and electrolyte conserving functions of the kidneys.
These five major classes of medications are discussed in more detail
Measurements at Home for Months before Starting Drugs
Before starting medications in non-emergency situations, people with
concerns about their blood pressure should first, buy a good quality
blood pressure cuff (an oscillometric monitor for $50 to $100) and use
it to monitor their blood pressure at home.1 I suggest they
then record the values several times a week and take these numbers to
their private doctor for further discussion.
A sustained elevation of blood pressure to 160/100 mmHg or greater over
months suggests the need for treatment with medication.2 A
word of caution: If you do start blood pressure-lowering medications,
avoid overly aggressive treatment. In general, reducing blood pressure
below 140/90 mmHg with medication is not beneficial and actually will
increase the risk of heart attacks, strokes, and death.3,4 A
recent review by the well-respected Cochrane Collaboration concluded
with: “Treating patients to lower than standard BP targets,
≤140-160/90-100 mmHg, does not reduce mortality or morbidity.”5
Chlorthalidone Is the Drug of Choice
Chlorthalidone is an oral diuretic (a water pill taken by mouth) with a
prolonged action of 48 to 72 hours and low toxicity. Diuretics lower
blood pressure by reducing fluid volume, which decreases the output of
the heart causing the blood pressure to fall. Doctors and patients often
believe that all diuretics have similar benefits. This is not the case,
and chlorthalidone is the preferred kind of diuretic for most patients.6,7
In 1990, the Multiple Risk Factor Intervention Trial (MRFIT) reported a
reduction in nonfatal cardiovascular events when the diuretic treatment
was changed to replace hydrochlorothiazide (HCTZ) with chlorthalidone in
men at high risk for coronary heart disease.8 Chlorthalidone
is also more effective at lowering systolic blood pressure (the top
number) than HCTZ. The starting dosage used was 12.5 to 25 mg daily; but
the dosage can be increased to 50 to 100 mg daily. All patients
receiving chlorthalidone should be checked after one month for evidence
of fluid or electrolyte imbalance: namely, low sodium, low chloride, and
low potassium (by blood tests). Other periodic laboratory tests should
be performed to look for adverse effects from this potent diuretic. For
example, blood levels of cholesterol, triglycerides and uric acid can be
increased by this medication. Chlorthalidone is inexpensive; a 30-day
supply is $4 and a 90-day supply is $10 for 25 or 50 mg tablets at
I No Longer Routinely Prescribe Beta-blockers
For many years beta-blockers were considered one of the first line
therapies for the treatment of hypertension. Current evidence suggests
that beta-blockers (like Atenolol) should not be prescribed unless there
is some other reason for their use (like atrial fibrillation, heart
failure, or myocardial infarction).9 A recent Cochrane
Collaboration concluded: “The available evidence does not support the
use of beta-blockers as first-line drugs in the treatment of
hypertension. This conclusion is based on the relatively weak effect of
beta-blockers to reduce stroke and the absence of an effect on coronary
heart disease when compared to placebo or no treatment.”10
Examples of commonly prescribed beta-blockers are: acebutolol (Sectral),
atenolol (Tenormin), betaxolol (Kerlone), betaxolol (Betoptic, Betoptic
S), bisoprolol fumarate (Zebeta), carteolol (Cartrol), carvedilol (Coreg),
esmolol (Brevibloc), labetalol (Trandate, Normodyne), metoprolol (Lopressor,
Toprol XL), nadolol (Corgard), nebivolol (Bystolic), penbutolol (Levatol),
pindolol (Visken), propranolol (Inderal, InnoPran), sotalol (Betapace),
and timolol (Blocadren).
Never Prescribe Calcium Channel Blockers
blockers are also called “calcium antagonists” and “calcium blockers.”
They may decrease the heart's pumping strength and relax the blood
vessels, and are commonly used to treat high blood pressure, angina
(chest pain), and some arrhythmias (abnormal heart rhythms). However,
they increase the risk of dying from heart disease and cancer
(especially breast cancer), and the risk of developing
glaucoma, suicide, and bleeding.11-17
Examples of commonly prescribed calcium channel blockers are: amlodipine
(Norvasc), clevidipine (Cleviprex), diltiazem (Cardizem), felodipine (Plendil),
isradipine (Dynacirc), nifedipine (Adalat, Procardia), nicardipine (Cardene),
nimodipine (Nimotop), nisoldipine (Sular), and verapamil (Calan, Isoptin).
Never Prescribe Angiotensin Receptor Blockers (ARBs)
Angiotensin is a hormone found in the body that causes blood vessels to
constrict, resulting in higher blood pressure and extra work on the
heart. Angiotensin receptor blockers (ARBs), also called angiotensin II
receptor antagonists, prevent angiotensin from binding to its receptor
in the walls of the blood vessels. This results in a lower blood
pressure. These medications are often prescribed because they are less
likely to cause a chronic cough than medications called angiotensin
converting enzyme inhibitors (ACE Inhibitors), which also work on the
“angiotensin system” to control high blood pressure.
Convincing evidence shows that angiotensin receptor blockers (unlike ACE
inhibitors) increase the rates of myocardial infarction (heart attacks)
despite their beneficial effects on reducing blood pressure.18
Examples of commonly prescribed angiotensin receptor blockers are:
candesartan (Atacand), eprosartan (Tevetan), irbesartan (Avapro),
telmisartan (Mycardis), valsartan (Diovan), and losartan (Cozaar).
ACE Inhibitors Are
Less Beneficial and More Dangerous Than Advertised
Angiotensin converting enzyme inhibitors (ACE Inhibitors) have been used
for decades to treat hypertension and heart disease. Their main selling
point is that they are said to be “renal-protective,” meaning they help
protect the kidneys from failing, especially for people with already
existing kidney disease and/or diabetes. However, their value for
protecting the kidneys has been largely refuted.20-23 The
ALLHAT data (the largest antihypertensive trial and the second largest
lipid-lowering trial) showed that among those patients with diabetes,
more patients in the ACE inhibitor (lisinopril) group progressed to end
stage kidney failure compared with the chlorthalidone group.23
Acute and chronic kidney failure from the use of these drugs is also
reported (and is much more common than most doctors realize).19,23
Examples of commonly prescribed ACE inhibitors are: benzapril (Lotensin),
captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril),
lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon),
quinapril (Accupril), ramipril (Altace), and trandolapril (Mavik).
Medication Benefits Are Oversold
Not surprisingly, pharmaceutical companies make great efforts to
advertise the benefits of their products and to cover up the harms. To
be more blunt, these companies lie to doctors, patients, medical
journals, and the media.24 One common method used is to
report unimportant benefits from use of their products, such as lowering
the blood pressure, rather than reporting very important end points like
staying alive and reducing the risk of a stroke or heart attack.
They also report “relative benefits” rather than “absolute benefits.”
For example, the risk of stroke over five years is fifteen cases per
thousand for untreated patients and nine cases for those actively
treated with medications.25 The relative risk reduction is 15
minus 9 divided by 15 or a 40% reduction. Forty percent sounds like a
great benefit. However, figuring more honestly with reports of the
absolute benefit are far less impressive. The absolute reduction in
stroke from treatment with medication is 15 minus 9 strokes, which
equals only 6 strokes prevented after treating a thousand people with
medication for five years. In other words, annually, one stroke is
prevented by treating one thousand patients. That’s a lot of money spent
and side effects suffered for a very low absolute benefit. (Would you
trade sexual dysfunction for this one in a thousand possible benefit?)
The bottom line is this: Make all efforts to avoid the need for
medications or any other medical services by staying healthy. This means
following the McDougall diet, exercising and practicing clean habits.
1) Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT,
Goff D. Call to Action on Use and Reimbursement for Home Blood
Pressure Monitoring: Executive Summary. A Joint Scientific Statement
From the American Heart Association, American Society of
Hypertension, and Preventive Cardiovascular Nurses Association.
Hypertension. 2008 May 22.
2) Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF,
Sever PS, Thom SM; BHS guidelines working party, for the British
Hypertension Society. British Hypertension Society guidelines for
hypertension management 2004 (BHS-IV): summary. BMJ. 2004 Mar
5) Arguedas JA, Perez MI, Wright JM. Treatment blood pressure
targets for hypertension. Cochrane Database Syst Rev. 2009
7) The Medical
Letter, Volume 51 (Issue 1305)
February 9, 2009
8) Carter BL, Ernst ME, Cohen JD. Hydrochlorothiazide versus
chlorthalidone: evidence supporting their interchangeability.
9) Carlberg B, Samuelsson O, Lindholm LH. Atenolol in hypertension:
is it a wise choice? Lancet. 2004 Nov 6;364(9446):1684-9.
10) Wiysonge CS, Bradley H, Mayosi BM, Maroney R, Mbewu A, Opie LH,
Volmink J. Beta-blockers for Hypertension. Cochrane Database Syst
Rev. 2007 Jan 24;(1):CD002003.
11) Psaty BM, Heckbert SR, Koepsell TD, Siscovick DS, Raghunathan
TE, Weiss NS, Rosendaal FR, Lemaitre RN, Smith NL, Wahl PW, et al.
The risk of myocardial infarction associated with antihypertensive
drug therapies. JAMA. 1995 Aug 23-30;274(8):620-5.
12) Beiderbeck-Noll AB, Sturkenboom MC, van der Linden PD, Herings
RM, Hofman A, Coebergh JW, Leufkens HG, Stricker BH. Verapamil is
associated with an increased risk of cancer in the elderly: the
Rotterdam study. Eur J Cancer. 2003 Jan;39(1):98-105.
13) Fitzpatrick AL, Daling JR, Furberg CD, Kronmal RA, Weissfeld JL.
Use of calcium channel blockers and breast carcinoma risk in
postmenopausal women. Cancer. 1997 Oct 15;80(8):1438-47.
14) Pahor M, Guralnik JM, Ferrucci L, Corti MC, Salive ME, Cerhan
JR, Wallace RB, Havlik RJ. Calcium-channel blockade and incidence
of cancer in aged populations. Lancet. 1996 Aug
15) Lindberg G, Bingefors K, Ranstam J, Rastam L, Melander A. Use
of calcium channel blockers and risk of suicide: ecological findings
confirmed in population based cohort study. BMJ. 1998 Mar
16) Pahor M, Guralnik JM, Furberg CD, Carbonin P, Havlik R. Risk
of gastrointestinal haemorrhage with calcium antagonists in
hypertensive persons over 67 years old. Lancet. 1996 Apr
17) Müskens RP, de Voogd S, Wolfs RC, Witteman JC, Hofman A, de Jong
PT, Stricker BH, Jansonius NM. Systemic antihypertensive medication
and incident open-angle glaucoma. Ophthalmology. 2007
18) Verma S, Strauss M. Angiotensin receptor blockers and
myocardial infarction. These drugs may increase myocardial
infarction – and patients may need to be told. BMJ 2004 Nov
19) Onuigbo MAC. Reno-prevention vs reno-protection: a critical
re-appraisal of the evidence-base from the large RAAS blockade
trials after ONTARGET—a call for more circumspection. QJM.
20) Suissa S, Hutchinson T, Brophy JM, Kezouh A. ACE-inhibitor use
and the long-term risk of renal failure in diabetes. Kidney Int.
21) Mann JF, Schmieder RE, McQueen M; et al, ONTARGET investigators.
Renal outcomes with telmisartan, ramipril, or both, in people at
high vascular risk (the ONTARGET study): a multicentre, randomised,
double-blind, controlled trial. Lancet.
22) Yusuf S, Teo KK, Pogue J; et al, ONTARGET Investigators.
Telmisartan, ramipril, or both in patients at high risk for vascular
events. N Engl J Med. 2008;358(15):1547-1559.
23) Onuigbo MAC. Analytical review of the evidence for
renoprotection by renin-angiotensin-aldosterone system blockade in
chronic kidney disease—a call for caution. Nephron Clin Pract.
24) John P. A. Ioannidis. Adverse Events in Randomized Trials:
Neglected, Restricted, Distorted, and Silenced. Arch Intern Med.
25) Cook RJ, Sackett DL. The number needed to treat: a clinically
useful measure of treatment effect. BMJ. 1995 Feb
<<< Return to Newsletter Home Page
2009 John McDougall All Rights Reserved